Cirrhotic pulmonary tuberculosis is characterized by a large overgrowth of scar tissue, among which active tuberculous foci are stored, causing periodic exacerbations and, possibly, poor bacterial excretion.

Cirrhotic tuberculosis includes processes in which:

        Tuberculous changes in the lungs with clinical manifestations of the activity of the process;

        Tendency to periodic exacerbations;

        The possibility of periodic appearance of scanty bacterial excretion.

If caverns are detected against the background of cirrhosis, then this testifies in favor of fibro-cavernous tuberculosis, and the absence of signs of activity indicates post-tuberculous cirrhosis.

Cirrhotic tuberculosis is segmental and lobar, limited and widespread, unilateral and bilateral.

Pathogenesis

Cirrhosis is the proliferation of connective tissue in the parenchymal organ, which causes a restructuring of its structure, compaction and deformation. The formation of cirrhosis is due to dysregulation of connective tissue growth, stimulation of collagen formation.

Bronchogenic cirrhosis – occurs after tuberculosis of the intrathoracic lymph nodes complicated by atelectasis. After a month or more, cirrhotic changes develop in the area that has become stale.

Pneumogenic cirrhosis — develops as a result of:

a) infiltrative tuberculosis (lobitis) – there is a germination of connective tissue in the zone of specific changes;

b) chronic disseminated tuberculosis – connective tissue grows in the foci and vessels in both lungs;

c) fibro-cavernous tuberculosis.

Pleurogenic cirrhosis – the cause of such cirrhosis is a pathological process in the pleura, for example, purulent pleurisy, when the connective tissue grows from the pleura into the lung. The airiness of the lungs is preserved, but the pleura becomes rigid, and the mobility of the lungs during breathing is sharply limited.

Pathomorphology

Cirrhotic pulmonary tuberculosis is primarily characterized by the development of connective tissue. The bronchi are deformed, their structure is broken, which causes the development of bronchiectasis. The vessels are narrowed, multiple arteriovenous anstomoses are available. The lung with cirrhotic tuberculosis is reduced in volume, deformed and compacted. With pleurogenic cirrhosis, the pleura is significantly thickened, resembles a carapace that covers the entire lung.

According to the degree of development of connective tissue, sclerosis, fibrosis and cirrhosis are distinguished .

Sclerosis ( pneumosclerosis ) of the lungs is characterized by the diffuse development of gently: scar tissue, but their airiness is preserved. Scar tissue grows between the alveoli, as a result of which the elasticity of the lung tissue is impaired, and therefore lung emphysema often develops.

Pulmonary fibrosis is characterized by the development of coarse fibrous connective tissue in a limited area of ​​the lung. The airiness of the affected area is partially preserved. Cirrhosis of the lungs is characterized by the intensive development of connective tissue, as a result of which the lung becomes airless.

Symptoms

Cirrhotic tuberculosis can have a long course with mild symptoms. More often, patients are concerned about fatigue, cough with sputum production, shortness of breath, extrasystole, which indicates the development of pulmonary heart disease. Bacterial excretion for cirrhosis is not characteristic. The presence of bronchiectasis (occur due to a violation of the structure of the bronchi) contributes to the attachment of a secondary infection. Therefore, periods of exacerbation of the process may be due to the activation of both specific and non-specific infections.

As a result of shrinkage of the lung in patients, a chest wall retraction is observed. Therefore, on the cirrhosis side during examination, there is a lag in the chest in the act of breathing. The cardiac impulse is displaced, and sometimes pulsation of the pulmonary artery is seen in the II intercostal space. Above the cirrhotic lung, voice trembling is intensified, dullness is percussion, auscultatory-sounding scarring rales that have a characteristic creaky hue and are heard against the background of bronchial breathing.

An X-ray sign of lung cirrhosis is the displacement of the mediastinal organs to the affected side (“fork symptom”), described by G. G. Rubinstein, intense dimming and narrowing of the pulmonary field, heaviness from the root of the lung to the diaphragm (symptom of “weeping willow”).

Treatment of patients with cirrhosis of the lungs is reduced to the appointment of non-specific therapy aimed at normalizing heart function and reducing cough, pain, shortness of breath. If cirrhosis is unilateral and allows the general condition of the patient, pneumonectomy is indicated. Sometimes you can limit yourself to a lobectomy. In cases of bilateral cirrhosis, partial resection of the lungs is indicated. Patients who cannot be recommended for surgical treatment should periodically recover in sanatoriums, be constantly in the fresh air to train the cardiovascular system with dosed physical exercises. In the spring and autumn, preventive courses of antibacterial treatment are carried out.

Effects. Depend on the rate of progression of dysfunction of the cardiorespiratory system. Such patients die more often due to respiratory failure. Pulmonary cirrhosis ranks first among all forms of tuberculosis in the frequency of hemoptysis.

Differential diagnosis

If people with cirrhotic changes in the lungs are monitored for a long time in a TB dispensary, the diagnosis of cirrhotic tuberculosis is relatively simple. It should take into account such signs:

        long-term treatment and monitoring for pulmonary tuberculosis ;

        the presence of dense tuberculosis foci on the background of cirrhosis or in other parts of the lungs;

        periodically short-term bacterial excretion is possible.

Differential diagnosis of cirrhotic tuberculosis is carried out with cirrhosis of the lung after a non-specific inflammatory process (post-pneumatic cirrhosis), lung aplasia, stage III sarcoidosis.

Cirrhosis after a nonspecific inflammatory process . Patients with post-pneumatic cirrhosis indicate pneumonia, lung abscess, etc. The process is more often in the middle and lower parts of the lungs. A rich auscultatory picture (dry and wet rales) is inherent in both post-pneumatic and tuberculous cirrhosis, however, their localization is not the same (with post-pneumatic cirrhosis, pathological noises are heard more often over the lower parts of the lungs).

With cirrhosis of a specific and non-specific nature, bronchiectasis is formed, therefore, with cirrhosis of various etiologies, exacerbations of purulent sputum, high body temperature, sweating, and significant leukocytosis are possible. Therefore, multiple searches of the office are necessary to rule out cirrhotic pulmonary tuberculosis, in which short-term bacterial excretion is possible.

During an X-ray examination, attention should be paid to the localization of cirrhotic changes, the presence of dense focal shadows against cirrhosis and in other parts of the lungs (a sign of cirrhotic tuberculosis). Bronchoscopy with cirrhosis of a non-specific etiology reveals non-specific endobronchitis, purulent contents in the lumen of the bronchus, with cirrhotic tuberculosis – cicatricial changes after specific bronchitis.

Of decisive importance here is a long-term follow-up, which establishes the stability of the process, the absence of exacerbations of tuberculosis and stable abacteriality, confirmed by repeated sputum cultures. In the sputum there are no MBT (-), there is a nonspecific microflora.

Lung aplasia

Aplasia of the lung is a congenital defect, which is found more often in young people during a preventive fluorographic examination. Subjectively, such persons feel satisfactory, only at an advanced age or with the onset of infection do symptoms of intoxication and respiratory failure appear. As with cirrhotic tuberculosis, the x-ray shows a blackout and a decrease in the volume of the pulmonary field, a shift in the mediastinal organs to the side of the lesion. However, unlike cirrhotic tuberculosis, the shadow is homogeneous, and tubercular foci are not visible against its background.

Percussion reveals dullness, respiratory sounds are absent, while numerous dry and wet rales, frequent bronchial breathing are heard over cirrhosis of a specific and non-specific nature. With the introduction of a contrast medium into the bronchus, its cliff is visible, bronchial branches are absent. Computed tomography allows you to more accurately identify changes in the bronchial tree and establish a diagnosis.

Diagnostic criteria for lung aplasia:

• asymptomatic course, detection at a young age with an accidental x-ray examination;    

• X-ray: homogeneous dimming and a decrease in the volume of the corresponding pulmonary field, the absence of focal shadows on its background and in other parts of the lung;    

• percussion – dullness over the affected area, respiratory sounds are not heard;    

• developmental anomaly is confirmed by the introduction of radiopaque substances in the bronchus, computed tomography.    

Sarcoidosis III Art. Massive cirrhotic changes develop at the III stage of sarcoidosis of the respiratory system. They are mainly bilateral, therefore, sometimes resemble cirrhotic tuberculosis, which developed against the background of chronic disseminated pulmonary tuberculosis. Of great importance are the anamnesis data, long-term follow-up observation for sarcoidosis, the absence of MBT in sputum in the past and at the time of the examination. As with cirrhotic changes of a different nature, such patients have possible symptoms of chronic bronchitis , respiratory failure, and chronic pulmonary heart disease.

However, with cirrhotic tuberculosis, which developed against the background of disseminated pulmonary tuberculosis, cirrhotic changes are located in the upper parts of the lungs, the tops are wrinkled, upward dislocation of the roots is visible, in the form of “branches of weeping willow”, multiple dense tuberculous foci. With sarcoidosis, cirrhotic changes are located mainly in the basal zones, sometimes conglomerates of enlarged and compressed lymph nodes in the roots are visible, the volume of the lungs is reduced, the domes of the diaphragm are raised. The Mantoux test for sarcoidosis of all stages is negative or doubtful. Mycobacterium tuberculosis is not found in sputum.

Diagnostic criteria for sarcoidosis, art. III:

• long-term follow-up and treatment for sarcoidosis;    

• on the roentgenogram – cirrhotic changes mainly in the basal parts of the lungs, the absence of tuberculous foci;    

lack of office, negative or doubtful reaction to tuberculin.

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